Population Health Coordinator - LPN/MA

Job Title

Responsible for assisting in coordinating team-based care, to provide health services to individuals, through effective partnership with patients, their caregivers/families, community resources and members of the Care Team.

Essential Functions

• Serve as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources.
• Work with RN's and payers to plan and monitor patient care.
• Assess patient's unmet health and social needs.
• Facilitate patient access to appropriate medical and specialty providers.
• Educate patient and family/caregiver(s) about relevant community resources.
• Facilitate and attend meetings between care team, payers, and community resources, as needed
• Assist with the identification of "high-risk" patients (the chronically ill and those with special health care needs), and add these to the patient registry (or flag in EHR)
• Follow up and monitor patients via payer work lists to assist in scheduling and following patient chronic care diagnosis.
• Attend all Care Coordinator training courses/webinars and meetings
• Display knowledge of preventative health requirements
• Maintain regular and predictable attendance
• Perform other essential duties as assigned

Education/Experience/Skill Requirements

• Current Certified Medical Assistant certification or licensed practical nurse
• Two years' experience as a CCMA or LPN required
• BLS
• Previous experience in caring for chronic disease patients preferred
• Two years' experience in clinical or community health setting preferred
• Previous Care Coordination, Case Management or Home Health experience preferred
• Must be self-motivated and have the ability to work within the established policies, procedures and practices prescribed by the hospital/clinic.